5421 Riverbluff Parkway North Charleston, SC (843)

Transcription

1 Minor Child 5-12 years Client Information Packet Please take a moment to complete all of the following information. This information will assist us in getting to know you and what prompted you to seek assistance. Please fill in the blanks and check the appropriate response if choices are given. Thank you for taking the time to complete this information. Child information First Name: Last Name: Middle Initial: Name Used: School: Street Address: City: County: State Zip: Mailing Address (if different from above): Grade in school: Date of Birth: Present Age: Male Female Ethnicity: African-American Caucasian Hispanic Asian American Indian/Native American Other Parent Information - Father First Name: Last Name: Middle Initial: Street Address: City: County: State Zip: Mailing Address (if different from above): Address: Telephone Numbers: Home: Cell: Work: Pager: Date of Birth: Present Age: Ethnicity: African-American Caucasian Hispanic Asian American Indian/Native American Other 1

2 Marital History: Engaged Wedding Date Married Length of Time: Separated Length of time Divorced Length of Time: Remarried times Parent Information Mother First Name: Last Name: Middle Initial: Street Address: City: County: State Zip: Telephone Numbers: Home: Cell: Work: Pager: Address: Date of Birth: Present Age: Ethnicity: African-American Caucasian Hispanic Asian American Indian/Native American Other Marital History: Engaged Wedding Date Married Length of Time: Separated Length of time Divorced Length of Time: Remarried times Family Information - Children Living with you Children s Names: Yes No Custodial Information Age: Male Female Age: Male Female Age: Male Female Age: Male Female Age: Male Female The child being seen by a counselor is in the custody of Mother Father Both Other 2

3 If applicable, what is the custody arrangement for this child? Emergency Contact Information Name: Contact Numbers: Home: Work: Relationship: Pager: Cell: Family Faith/Religious Background Was mother raised in church? Yes No Denomination: Was father raised in church? Yes No Denomination: Does mother have a personal relationship with Christ? Yes No I don t know Does father have a personal relationship with Christ? Yes No I don t know Current Place of Worship: Pastor/Priest/Leader: Regular Attendance Occasional Attendance Seldom Attend Never Attend Are you seeking counseling services based on Christian principles? Yes No Referral Information Who referred you to the Riverbluff Discipleship Counseling Center? Self-Referral Friend Minister/Pastor Riverbluff Member Family Member Employer Psychiatrist Hospice/Home Health Hospital Doctor Attorney Other 3

4 Payment Information The cost of professional counseling is $80.00 for one contact hour or minute session or $ for the initial intake session which is minutes. Please indicate which type of payment method you will be using: I will be paying for counseling with cash or a check I would like to utilize my personal health insurance if the counselor is a provider for my insurance company. For all minor clients the parent bringing the child is responsible for payment for counseling fees. Clients are responsible for verifying their insurance coverage. I certify that I will accept full responsibility for payment of sessions and/or services rendered by the Riverbluff Discipleship Counseling Center (RDCC) and its counselors: Signature: Date: The RDCC will gladly file your insurance for you. However, fees for sessions are the ultimate responsibility of the client if the insurance company does not pay as expected. Primary Insurance Information (if applicable) Insurance Company: Address: Phone: Name of Insured Person: Address of Insured: Insured Date of Birth: / / SSN: Policy No: Group No: Relation to Client: Secondary Insurance Information (if applicable) Insurance Company: Address: Phone: Name of Insured Person: Address of Insured: Insured Date of Birth: / / SSN: Policy No: Group No: Relation to Client: If you plan to use insurance, please complete pages

5 Child s Mental Health Information (Past and Present) Has this child been in counseling before? Yes No Dates What issues were addressed? Was it Helpful? Yes No If yes, how was it helpful? Has this child been given any mental health diagnosis? Yes No Please list any diagnoses that have been given to this child Past treatment Information: Medications: Dosage/Frequency: Dosage/Frequency: Suicidal thoughts/attempts Hospitalizations Current Treatment Information: Medications: Yes No Dosage/Frequency: Dosage/Frequency: Dosage/Frequency: Dosage/Frequency: Child s Health Information (non-psychiatric care) Present Physical Condition: Excellent Good Fair Poor Other Medications: Dosage/Frequency: Dosage/Frequency: Dosage/Frequency: Recent Surgeries: Date: Physician Name: Phone: 5

6 Reason for seeking Counseling Please state reason/reasons for seeking counseling for this child: What do you want to be different for this child? Are you willing to participate in the therapeutic process? Areas of Concern (5-12 years old) Please indicate whether each of the following issues is a possible area of concern: Aggression, violent when angry. Yes No N/A Anger, excessive arguing, irritability. Yes No N/A Anxiety, nervousness, tension Yes No N/A Attention, concentration distractibility. Yes No N/A Compulsions, obsessions (thoughts or actions that repeat themselves) Yes No N/A Delusions (false ideas) Yes No N/A 6

7 Depression, low mood, sadness, crying Yes No N/A Difficulty with transitions and/or changes Yes No N/A Drastic mood swings. Yes No N/A Fears, phobias Yes No N/A Frequent tantrums. Yes No N/A If yes, please explain the frequency and nature of the tantrums: Getting along with peers, lack of friendships Yes No N/A Health, illness, medical issues Yes No N/A Hyperactive Yes No N/A Impulsivity, loss of control, outbursts Yes No N/A Loss of loved-one, grief Yes No N/A Low self esteem Yes No N/A Motivation, laziness, low energy Yes No N/A 7

8 Oppositional/ defiant behavior Yes No N/A Oversensitivity to sound, light, touch Yes No N/A Panic or anxiety attacks Yes No N/A Self harming behaviors Yes No N/A Sleeping problems, nightmares, night terrors Yes No N/A Temper problems, self-control. Low frustration tolerance. Yes No N/A please explain: If yes, Weight, body image issues, eating problems Yes No N/A Withdrawal from family and/or peers Yes No N/A Any other issues or concerns: *** Please put a star by your top 3 areas of concern in the list above*** 8

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10 Additional Information Please answer the following questions: Has this child experienced physical, sexual, emotional abuse or neglect? Yes No If yes, please explain: Has this child witnessed domestic violence? Yes No Please provide information about this child s school performance and behavior at school: 10

11 Statement of Understanding and Confidentiality I understand that the intake and/or counseling services my child receives through the Riverbluff Discipleship Counseling Center (RDCC) are being performed by a Licensed Counselor (LPC or LPC/I) who is a part of the RDCC Staff. I understand that the counseling center staff is under the supervision of the Director of Discipleship Counseling Ministries and the Director is under the supervision of a pastor who provides general oversight of all clients seen by the counselor. I understand that these individuals may receive information about the counseling my child receives for purposes of supervision, excluding any information that could identify me. I understand that any information we share (or is shared by an agent that I have identified and signed clearance for) will be held in strict confidence unless I sign a release of information. Even then, the information will only be released to the person/office identified and no other. I further understand that the release of information could occur if our counselor is ordered to do so by a court with good cause or as is mandated or allowed by the statutes governing the practice of the therapist. I am also aware that the counselor is mandated by law to intervene if he/she suspects that a child (under the age of eighteen) or an elder (over the age of sixty-five) or a vulnerable adult is currently endangered by abuse or if my child or I am a danger to myself or others. I understand the purpose of the services my child is receiving is to assist in achieving goals I will establish with the counselor in the initial sessions. I also understand that the ultimate purpose of the experience is to assist us identifying Biblical strategies for achieving the goals we have established and to (re)connect with Christ and His plan for us. I understand that we are free to leave at any time and are here voluntarily. I understand the RDCC staff will not use for clinical matters and that I can my therapist about appointments and other administrative issues, but that the counselor may not respond to s, except during business hours. I understand that I am discouraged from ing any personal content, as is not completely secure or confidential. If I choose to communicate with the RDCC by , I am aware that all s are retained in the logs of the Center s Internet service provider. While it is unlikely that someone will be looking at these logs, I understand that they are, in theory, available to be read by the system administrator(s) of the Internet service provider. I also understand that any s the RDCC staff may receive from me and any responses that the counselor sends to me may become a part of my legal record. Additionally, I understand that my counselor may use a smart phone that receives s and that the counselor may store my phone information on their phone. I understand that my counselor will protect my information on his/her cell phone through 11

12 the use of a security code, but that my counselor is not responsible if the phone is accessed by another person. I understand that we may encounter other members of the church and ministry staff as we enter the building and the counseling office. I understand that if we would prefer to meet at another location, other accommodations for meeting will be provided upon my request. I understand that the initial consultation includes a review of the paperwork necessary prior to the determination of services we will receive, as well as an opportunity to talk with the intake facilitator/counselor regarding the issues that have prompted me to seek assistance for my child. I am aware that the fee for professional counseling sessions is: $80/ 1 hour session and $160 for the initial intake session, which will last minutes. I understand that I am responsible for either paying this fee or providing adequate information for the RDCC staff to bill my insurance company for a portion of the fee. I understand that I am fully responsible for any allowable amount that my insurance company does not pay. I understand that if I am unable to pay this fee I must inform my counselor prior to the first appointment. I understand that each session will be approximately minutes in length, unless a different amount of time is agreed upon in advance of the session. I agree to make payment for services at the time of my appointment. I understand that I must give 24 hours notice of cancellation. The Discipleship Counseling Ministry chooses not to request payment for cancelled appointments, therefore, I will make every effort to notify the counselor in a reasonable amount of time should cancellation be necessary. I understand that if I habitually do not attend appointments my counselor will discuss this with me and may require me to pay a cancellation fee off $25. My signature constitutes my understanding of my rights to confidentiality and the limitations to this right. I have had the opportunity to discuss this with my child s counselor. Printed Name: Parent Signature Date 12

13 Please complete pages if you intend (now or in the future) to use insurance for payment at the Riverbluff Discipleship Counseling Center. Insurance Claim Information Sheet The following information will assist you in preparing for the claim filing process: 1. The intake forms must be filled out completely. All insurance information must be included as well as a copy of both sides of your insurance card. 2. To verify our coverage, call the toll-free number of your insurance company to request specific coverage information. (if there are several numbers listed on the back of your card, call the one associated with benefits, behavioral health or mental health). Ask the following of your Insurance Company: Do I have mental health coverage? Does it require me to meet a deductable? If so, amount of deductible. Have I met it? Does it cover services rendered by a Licensed Professional Counselor (LPC)?. Must the therapist I see be on a preferred provider list?. Is my therapist (give them your RDCC counselor s name) on that list?. What is my required co-payment or co-insurance?. Must sessions be pre-certified?. If the insurance representative inquires about a reason for counseling give a general category of stress or adjustment disorder. If primary physician or the therapist must start the precertification, what number must be called to do this? ( ) If sessions are approved, what is the authorization number? Number of sessions approved? Start Date: End Date: To what address should my claim be sent? If you have questions or need assistance, please call the RDCC Office (843) and leave a message for the Intake Coordinator. 13

14 Certification and Authorization Information If you wish for RDCC to file for insurance reimbursement, all of the above information must be completed, as well as a copy made of your insurance card, so we can supply a statement acceptable by most companies. The following releases are also required to prepare and file insurance Note: Clients who wish us to file their claims are asked to pay for sessions in full until we receive written confirmation from their insurance company as to coverage amounts. All clients are asked to pay their portion for the therapy fee at the beginning of each session. Yes, please file my claims for me No, I plan to file my own claims (Note: Some insurance plans, such as Tri-Care, require us as providers to file the claims.) I certify that I will accept full responsibility for payment for sessions and/or services rendered in the event that my insurance company does not reimburse RDCC fully: Signature: Date: I authorize payment of medical benefits to Riverbluff Discipleship Counseling Center for services rendered. Signature: (Signature of insured or authorized person) Date: I authorize the release of any medical information necessary to process this claim. Signature: (Signature of insured or authorized person) Date: I authorize the release of my Outpatient Treatment Report to my Primary Care Physician. Signature: (Signature of insured or authorized person) Date: Statement of Understanding I have read and reviewed this document. I have completed it accurately. I have read, understand and have completed a Statement of Understanding. I understand everything that I have read and completed. Parent Signature: Date: 14

15 Please complete the highlighted sections of this form only 15

16 Recipient s Rights Notification 5421 Riverbluff Parkway As a recipient of services at The Discipleship Counseling Center, we would like to inform you of your rights as a client. The information contained in this notification explains your rights and the process of complaining if you believe your rights have been violated. Your rights as a client 1. Confidentiality. We will maintain your therapeutic and financial records in accordance with HIPAA regulations. 2. Complaints. We will investigate your complaints. 3. Suggestions. You are invited to suggest changes in any aspect of the services we provide. 4. Civil Rights. Your civil rights are protected by federal and state laws. 5. Cultural/spiritual/gender Issues. You may request services from someone with training or experiences from a specific cultural, spiritual, or gender orientation. If these services are not available, we will help you in the referral process. 6. Treatment. You have the right to take part in formulating your treatment plan. 7. Denial of services. You may refuse services offered to you and be informed of any potential consequences. 8. Record restrictions. You may request restrictions on the use of your protected health information; however, we are not required to agree with the request. 9. Availability of records. You have the right to obtain a copy and/or inspect your protected health information; however we may deny access to certain records in which we will discuss this decision with you. 10. Amendment of records. You have the right to request an amendment in your records; however, this request could be denied. If denied, your request will be kept in the records. 11. Medical/Legal Advice. You may discuss your treatment with your doctor or attorney. 12. Disclosures. You have the right to receive an accounting of disclosures of your protected health information that you have not authorized. Your rights to receive information: 1. Costs of services. We will inform you of how much you will pay. 2. Termination of services. You will be informed as to what behaviors or violations could lead to termination of services at our counseling center. 3. Confidentiality. You will be informed of the limits of confidentiality and how your protected health information will be used. Our ethical obligations: 1. We dedicate ourselves to serving the best interest of each client. 2. We will not discriminate between clients or professionals based on age, race, creed, disabilities, handicaps, preferences, or other personal concerns. 16

17 3. We maintain an objective and professional relationship with each client. 4. We respect the rights and views of other mental health professionals. 5. We will appropriately end services or refer clients to other programs when appropriate. 6. We will evaluate our personal limitations, strengths, biases, and effectiveness on an ongoing basis for the purpose of self-improvement. We will continually attain further education and training. 7. We hold respect for various institutional and managerial policies, but will help improve such policies if the best interest of the client is served. Client s responsibilities: 1. You are responsible for your financial obligations to the counseling center as outlined in the Statement of Understanding. 2. You are responsible for following the policies of the counseling center. 3. You are responsible to treat staff and fellow clients in a respectful, cordial manner in which their rights are not violated. 4. You are responsible to provide accurate information about yourself. What to do if you believe your rights have been violated: If you believe that your client rights have been violated contact our Director of Discipleship Counseling. Acknowledgement of Understanding I have read and understand my rights as a client of The Discipleship Counseling Center. Parent Signature: Date: 17

18 Emergency Contact Information (Please review and keep this information) 5421 Riverbluff Parkway Riverbluff Church provides counseling services on an outpatient basis; therefore, there are times that our services are not available. Riverbluff Discipleship Counseling Center office hours are 9:00 a.m. 4:30 p.m. In non-emergency situations, messages can be left for your counselor at the Riverbluff Discipleship Counseling Center 24-hours a day. Calls will be returned within 24 hours, except on weekends and holidays, when they will be returned as soon as possible. Appointments are available Monday-Friday from 9:00 a.m. 4:00 p.m. and evening appointments are available on a limited basis. Other contact information is provided below, please follow the specific guidelines for each mode of contact: for emergency/crisis situations Please call the RDCC emergency line at x 1 and leave a message. The On-Duty counselor will contact you within 1 hour. If you need immediate assistance, please call 911. to share non-emergency information,- call the RDCC at and leave a message for your specific counselor. If you are unable to reach us during an emergency or crisis situation, please call (or have a friend or family member call) one of the following numbers: Crisis Line Mobile Crisis MUSC Access EMS 911 If during our work together there is concern for your safety or the safety of another due to your behavior or information you share, state law requires that we inform the individual or the authorities. 18